Medication Refill Requests Complete the form below to submit your requests Name and Contact Info of Person Submitting FormFirst Name *Last Name *Phone *Email Address *Days of medication left on hand *refill request may take up to 72 hours to completeMedication Requested and dosageMedication Requested and dosageMost medication refills will require a monthly appointment with your Primary Provider.•Refill requests will not be processed if Patient does not have a follow up appointment scheduled.•If you need a controlled substance evaluation appointment, please submit your request on our appointment tab or call the office phone number at (818) 600-2034.•Controlled substances, such as benzodiazepines and some ADHD medication will only be filled for a 30 day max supply as per state standards.Medication Requested and dosage *Please provide your current preferred pharmacy *Your Primary Provider? *select the optionDana MarkeeEmily Ashley IbrahimFarooque AzamNsreen JesriMichael JoanitisTiffany CooperYulia Koba AntoniadouSteven BerryClarito VillanuevaEmiliano BaquirKalpesh BhavsarSherwin WongWendi SellersDavid GueringerAdison Buongiorno-SmithJuliane LovichAmanda BerkowitzJeanne SandovalJoel PriceMadison LawrenceStanley MesenWendy RomoDeAdra JordanRubicela RodriguezAnna HadlockAnna Sealander-HulbertMarlon Carlo EstellaJeni MassiAlenika AndreevKathleen KimHannah Song KookElisa Fry LeonardChristiana RobinsonJasmin AlfonsoDavid SudykaPennie AlvarezTrenise RahmanGayane MelikyanAdriana Estella GuarderasAnthony CarletelloElizabeth WrayJessica PerezAmanda RomeroBrianne FlexenJulie WionsXiomara MoralesSathi DattaSend Message
